Rheumatoid arthritis (RA) is one of the 100 different kinds of arthritis affecting nearly 175 million people worldwide. While osteoarthritis is a common form of arthritis that affects people mostly over the age of 55, rheumatoid arthritis is not quite as straightforward. What is rheumatoid arthritis and what are common rheumatoid arthritis treatments?
What is rheumatoid arthritis?
RA can affect people as young as 20. Fully 50% of those diagnosed with rheumatoid arthritis are unable to work full-time within ten years of diagnosis. Rheumatoid arthritis is an autoimmune disorder that occurs mostly in developed countries. Symptoms of RA include:
- Pain and stiffness in the affected joints, especially after periods of rest or inactivity
- Redness and swelling
- Loss of appetite
- General feeling of being unwell (often termed “malaise”)
- Periods of pain flare-ups and remission (very few or no symptoms)
Because this condition can develop during a person’s most productive years, the cost of rheumatoid arthritis over a lifetime is high. While there is no cure for RA at this time, researchers have discovered potential rheumatoid arthritis treatments that are safe and effective and may actually help slow the progression of the disease.
Managing body mass index
The first and potentially easiest treatment to access is managing body mass index (BMI). Researchers at the Hospital for Special Surgery (HSS) have discovered that patients with RA who are underweight or overweight have fewer periods of remission. These periods of remission were also shorter.
In the study of 944 patients diagnosed with rheumatoid arthritis, researchers found that the 2% of underweight patients and 65% of overweight or obese patients were older, mostly female, and had less function than those patients with a healthy BMI (as classified by the World Health Organization). The overweight and underweight patients were also more likely to be smokers, another potential factor in remission of RA.
As Vivian Bykerk, M.D., principal investigator and director of the Inflammatory Arthritis Center at HSS, points out, it is vital to identify factors that patients can control when treating RA:
“It is important to identify possible factors we can modify to help patients with this disease. We also saw that those who smoked were less able to achieve sustained remission.”
Susan Goodman, M.D., a rheumatologist at HSS, was shocked by the addition of underweight patients who had fewer and shorter periods of remission:
“What’s striking is that if you look at the BMI classifications, all the patients in the underweight or overweight categories were much less likely to achieve sustained remission compared to those with a normal BMI.”
The takeaway from this study is that maintaining an appropriate BMI is a crucial first step in managing symptoms of rheumatoid arthritis. Taking steps to achieve and maintain a healthy BMI is well within the control of the patient and should be the first treatment option.
COBRA Slim rheumatoid arthritis treatments
As far as drug-based interventions, there are significant developments on that front as well. A method of administering effective medications for rheumatoid arthritis resulted in similar relief for patients but with fewer harmful side effects and at a cheaper cost. The treatment protocol is called COBRA Slim. It uses the same proven effective medications but in different combination.
De Cock divided 290 patients with rheumatoid arthritis into three groups and provided the following COBRA treatment protocols:
- Classic (methotrexate, sulfasalazine, and a high first dose of glucocorticoids)
- Slim (methotrexate and a moderate dose of glucocorticoids)
- Avant-Garde (methotrexate, leflunomide, and a moderate dose of glucocorticoids)
All three protocols were very effective, with remission achieved for 70% of patients within 16 weeks. The difference was in the side effects. The COBRA Slim treatment utilized half of the medication of the other two. It resulted in half as many side effects. This treatment was also much easier to utilize on a daily basis. This was a factor that could contribute to better patient compliance.
Diederik De Cock, doctoral researcher at the Research Centre for Skeletal Biology and Engineering (KU Leuven), pointed out that the affordability of the treatment puts this within reach of many more patients, a bonus for those at the poverty level who experience earlier onset of rheumatoid arthritis:
“Methotrexate is very affordable, as are [steroids]. Implementing this therapy across Flanders would mean substantial savings. At the moment, RA treatment is not yet adequately standardized in Belgium, and this leads to treatment inefficiencies. As a result, more patients require expensive second-line anti-rheumatic therapies known as biologicals, which can cost up to 15,000 euros per year. By comparison, the COBRA Slim strategy costs less than 1,000 euros. In other words, we can treat up to 15 patients for the same price as a year of treatment with a biological.”
This research originally came out in 2014. Since then, a two-year investigator-initiated randomized pragmatic open-label superiority RA trial looked at its use. Researchers concluded that:
“MTX with a moderate-dose GC remission induction scheme (COBRA Slim) seems an effective, safe, low-cost and feasible initial treatment strategy for patients with ERA regardless of their prognostic profile, provided a treat-to-target approach is followed.”
Avoiding cartilage damage
Once a patient is diagnosed with rheumatoid arthritis, the goal has traditionally been to slow the progression of the disease. What if instead there was a treatment that went beyond that to actually repair damaged bone? A study from the La Jolla Institute for Allergy and Immunology has found a new drug target that can stop cartilage damage in its tracks.
Nunzio Bottini, M.D. Ph.D., associate professor at La Jolla Institute and associate professor of medicine at the University of California, San Diego was the lead author of the study that looked at the activity of fibroblast-like synoviocytes (FLS). The FLS are located in the synovial fluid of each joint and usually provide joint lubrication. When the immune system is triggered, these formerly peaceful cells begin to attack the cartilage, breaking it down. They also cause bone deterioration.
Bottini wanted to find a way to stop the fibroblast-like synoviocytes from inflicting further damage to the joint after inflammation was under control:
“Even if your inflammation is completely under control with the help of current therapies — and they are excellent — the damage to the skeletal structure is not necessarily arrested in the long term because synoviocytes continue to cause damage. And although synoviocytes are considered the main effectors of cartilage damage in rheumatoid arthritis there’s no therapy directed against them.”
Postdoctoral researcher Karen M. Doody, Ph.D, discovered an enzyme known as RPTPσ (receptor protein tyrosine phosphatase sigma) on the surface of FLS. This enzyme is responsible for keeping the FLS in check, blocking it from attacking and destroying cartilage and bone. The team’s goal was to find a way to activate that response in patients with rheumatoid arthritis. The key to this was to remove the biological blocks that prevented the receptor protein tyrosine phosphatase sigma from kicking into action. The team found that this action resulted in less cartilage damage. Further, this treatment did not interfere with other rheumatoid arthritis treatments.
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What rheumatoid arthritis treatments do you currently use?